<!DOCTYPE html>
<html lang="zh" xmlns:th="http://www.thymeleaf.org" >
<head>
    <th:block th:include="include :: header('新增慢病报销')" />
    <th:block th:include="include :: datetimepicker-css" />
</head>
<body class="white-bg">
    <div class="wrapper wrapper-content animated fadeInRight ibox-content">
        <form class="form-horizontal m" id="form-recompense-add">
            <div class="form-group">    
                <label class="col-sm-3 control-label">医院发票号：</label>
                <div class="col-sm-8">
                    <input name="mrNumber" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">预报销金额：</label>
                <div class="col-sm-8">
                    <input name="beforeFee" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">实际报销金额：</label>
                <div class="col-sm-8">
                    <input name="actualFee" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">参合农民身份证号：</label>
                <div class="col-sm-8">
                    <input name="idCard" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">领款时间：</label>
                <div class="col-sm-8">
                    <div class="input-group date">
                        <input name="miTime" class="form-control" placeholder="yyyy-MM-dd" type="text">
                        <span class="input-group-addon"><i class="fa fa-calendar"></i></span>
                    </div>
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">操作员：</label>
                <div class="col-sm-8">
                    <input name="miPerson" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">姓名：</label>
                <div class="col-sm-8">
                    <input name="name" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">性别：</label>
                <div class="col-sm-8">
                    <select name="sex" class="form-control m-b">
                        <option value="">所有</option>
                    </select>
                    <span class="help-block m-b-none"><i class="fa fa-info-circle"></i> 代码生成请选择字典属性</span>
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">农合证号：</label>
                <div class="col-sm-8">
                    <input name="nonghecard" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">地址：</label>
                <div class="col-sm-8">
                    <input name="address" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">疾病名称：</label>
                <div class="col-sm-8">
                    <input name="illness" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">累计报销金额：</label>
                <div class="col-sm-8">
                    <input name="mubFee" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">年度：</label>
                <div class="col-sm-8">
                    <input name="year" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">乡镇农合办经办人审批：</label>
                <div class="col-sm-8">
                    <input name="approvalXz" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">县农经办人汇款审批：</label>
                <div class="col-sm-8">
                    <input name="approvalXn" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">报销时间：</label>
                <div class="col-sm-8">
                    <div class="input-group date">
                        <input name="reimbursementTime" class="form-control" placeholder="yyyy-MM-dd" type="text">
                        <span class="input-group-addon"><i class="fa fa-calendar"></i></span>
                    </div>
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">乡镇农合办经办人审批时间：</label>
                <div class="col-sm-8">
                    <div class="input-group date">
                        <input name="approvalXzTime" class="form-control" placeholder="yyyy-MM-dd" type="text">
                        <span class="input-group-addon"><i class="fa fa-calendar"></i></span>
                    </div>
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">县农经办人汇款审批时间：</label>
                <div class="col-sm-8">
                    <div class="input-group date">
                        <input name="approvalXnTime" class="form-control" placeholder="yyyy-MM-dd" type="text">
                        <span class="input-group-addon"><i class="fa fa-calendar"></i></span>
                    </div>
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">报销编号：</label>
                <div class="col-sm-8">
                    <input name="reimbursementNumber" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">办理时间：</label>
                <div class="col-sm-8">
                    <div class="input-group date">
                        <input name="handleTime" class="form-control" placeholder="yyyy-MM-dd" type="text">
                        <span class="input-group-addon"><i class="fa fa-calendar"></i></span>
                    </div>
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">行政区域：</label>
                <div class="col-sm-8">
                    <input name="area" class="form-control" type="text">
                </div>
            </div>
        </form>
    </div>
    <th:block th:include="include :: footer" />
    <th:block th:include="include :: datetimepicker-js" />
    <script th:inline="javascript">
        var prefix = ctx + "system/recompense"
        $("#form-recompense-add").validate({
            focusCleanup: true
        });

        function submitHandler() {
            if ($.validate.form()) {
                $.operate.save(prefix + "/add", $('#form-recompense-add').serialize());
            }
        }

        $("input[name='miTime']").datetimepicker({
            format: "yyyy-mm-dd",
            minView: "month",
            autoclose: true
        });

        $("input[name='reimbursementTime']").datetimepicker({
            format: "yyyy-mm-dd",
            minView: "month",
            autoclose: true
        });

        $("input[name='approvalXzTime']").datetimepicker({
            format: "yyyy-mm-dd",
            minView: "month",
            autoclose: true
        });

        $("input[name='approvalXnTime']").datetimepicker({
            format: "yyyy-mm-dd",
            minView: "month",
            autoclose: true
        });

        $("input[name='handleTime']").datetimepicker({
            format: "yyyy-mm-dd",
            minView: "month",
            autoclose: true
        });
    </script>
</body>
</html>